Youth Medical/Liability Release | Hope Community Church of Agawam

Medical and Liability Release

Please complete the following form to electronically approve the medical and liability release for your child to participate in Hope Community Church youth ministry activities. This form must be completed by a parent or legal guardian.

Name (Required)

Email Address (Required)

Student's Name: (Required)

First and Last required

Student's Date of Birth: (Required)

Contact Information

Student's Phone Number:

Parent(s)/Legal Guardians that student lives with: (Required)

Parent(s)/Legal Guardian's phone number: (Required)

Home Address

Street Address: (Required)

City: (Required)

State: (Required)

Zip Code: (Required)

Emergency Contact Info

This should emergency contacts in case parents/guardians cannot be contacted.

Emergency Contact 1: (Required)

Please provide a name and phone number.

Emergency Contact 2:

Please provide a name and phone number.

Doctor: (Required)

Doctor's Address:

Doctor's Phone Number: (Required)

School Info

School Grade:

School:

Health History

Known Allergies:

Select all that apply.

Drugs

Food

Insect bites & stings

Other

If you checked any of the above, then please list specific allergies and the typical treatment.

Other Known Conditions

Please check all that apply.

Heart condition

Frequent colds

Frequent upset stomach

Physical handicap

Chronic asthma

Epilepsy

Other

If you checked any of the above, then please give details.

Please list any medications required and provide dosage as necessary.

Date of last tenanus shot: (Required)

Can the student swim? (Required)

Please list any swimming restrictions.

Note: Hope Community Church typically does not provide a lifeguard for any activities.

Please list any activity restrictions.

Insurance Information

Our church's insurance is only secondary insurance If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is involved in a church-related activity.

Do you have health insurance? (Required)

Name of Insurance Provider:

Insurance Provider Phone Number:

Insurance Policy Number:

Claims Address:

Liability Release Statement

Every student ministry activity sponsored by this church is carefully planned and supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related activities. He or she agrees not to hold Hope Community Church or its employees or volunteer assistants liable for damages, losses, or injuries to the person named above. He or she also understands that the signature below is for both a medical and a liability release.

Medical Release Statement

In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by Hope Community Church leadership to hospitalize, secure proper treatment, and/or order an injection, anesthesia, or surgery for the person named above, as deemed necessary. I also agree to accept full financial responsibility for the cost of such treatment.

E-Signature Disclosure (Required)

I agree and understand that by signing with an Electronic Signature, that the electronic signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

I affirm that I am a parent or legal guardian of the named student. (Required)

Electronic Signature (Required)

Type your full legal name to electronically sign this release.

Today's date: (Required)

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Hope Community Church

152 S Westfield St, Feeding Hills, MA 01030

(413) 786-2445

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